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Factors Associated with Do-Not-Resuscitate Orders: Patients' Preferences, Prognoses, and Physicians' Judgments

Rosemarie B. Hakim, PhD; Joan M. Teno, MD; Frank E. Harrell Jr., PhD; William A. Knaus, MD; Neil Wenger, MD; Russell S. Phillips, MD; Peter Layde, MD; Robert Califf, MD; Alfred F. Connors Jr., MD; Joanne Lynn, MD, SUPPORT Investigators*
[+] Article and Author Information

From George Washington University Medical Center, Washington, D.C.; Duke University Medical Center, Durham, North Carolina; University of Los Angeles, Los Angeles, California; Beth Israel Hospital, Boston, Massachusetts; Medical College of Wisconsin, Milwaukee, Wisconsin; Marshfield Clinic, Marshfield, Wisconsin; and MetroHealth Medical Center, Cleveland, Ohio. Grant Support: By the Robert Wood Johnson Foundation. Requests for Reprints: Joan M. Teno, MD, MS, Center to Improve Care of the Dying, George Washington Medical Center, 1001 22nd Street, Suite 820, Washington, DC 20037. Current Author Addresses: Dr. Hakim: The Health Care Financing Administration, 7850 Security Boulevard, Baltimore, MD 21244. Drs. Teno and Lynn: Center to Improve Care of the Dying, George Washington Medical Center, 1001 22nd Street, Suite 820, Washington, DC 20037.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1996;125(4):284-293. doi:10.7326/0003-4819-125-4-199608150-00005
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Background: Medical treatment decisions should be based on the preferences of informed patients or their proxies and on the expected outcomes of treatment. Because seriously ill patients are at risk for cardiac arrest, examination of do-not-resuscitate (DNR) practices affecting them provides useful insights into the associations between various factors and medical decision making.

Objective: To examine the association between patients' preferences for resuscitation (along with other patient and physician characteristics) and the frequency and timing of DNR orders.

Design: Prospective cohort study.

Setting: 5 teaching hospitals.

Patients: 6802 seriously ill hospitalized patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) between 1989 and 1994.

Measurements: Patients and their surrogates were interviewed about patients' cardiopulmonary resuscitation preferences, medical records were reviewed to determine disease severity, and a multivariable regression model was constructed to predict the time to the first DNR order.

Results: The patients' preference for cardiopulmonary resuscitation was the most important predictor of the timing of DNR orders, but only 52% of patients who preferred not to be resuscitated actually had DNR orders written. The probability of surviving for 2 months was the next most important predictor of the timing of DNR orders. Although DNR orders were not linearly related to the probability of surviving for 2 months, they were written earlier and more frequently for patients with a 50% or lower probability of surviving for 2 months. Orders were written more quickly for patients older than 75 years of age, regardless of prognosis. After adjustment for these and other influential patient characteristics, the use and timing of DNR orders varied significantly among physician specialties and among hospitals.

Conclusions: Patients' preferences and short-term prognoses are associated with the timing of DNR orders. However, the substantial variation seen among hospital sites and among physician specialties suggests that there is room for improvement. In this study, DNR orders were written earlier for patients older than 75 years of age, regardless of prognosis. This finding suggests that physicians may be using age in a way that is inconsistent with the reported association between age and survival. The process for making decisions about DNR orders needs to be improved if such orders are to routinely and accurately reflect patients' preferences and probable outcomes.

*For a list of the SUPPORT investigators, see the Appendix.

Figures

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Figure 1. DNR = do-not-resuscitate; SUPPORT = the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.
Diagram of final patient sample.
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Grahic Jump Location
Figure 2.
Relative contributions of predictive variables in the model for time to do-not-resuscitate order, measured by the Wald chi-square value accounted for by each variable.
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Grahic Jump Location
Figure 3. Data are plotted as a function of patient age ( ) and as a function of the probability of 2-month survival as estimated by the SUPPORT prognostic model ( ). Dotted lines are 95% Cls.
Adjusted probability that a typical patient enrolled in SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) would have a do-not-resuscitate (DNR) order by study day 30.top[17]bottom
Grahic Jump Location
Grahic Jump Location
Figure 4. Data show the variability of the writing of DNR orders among physician clinical specialties in the five SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) hospitals. MIC = medical intensive care.
Unadjusted rate of do-not-resuscitate (DNR) orders by study institution and physician clinical specialty.
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